HomeMy WebLinkAbout1996 well & boring sealing record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
WELL H 10 2 8.6 7
County Name BORING LOCATION WELL AND BORING SEALING RECORD
Sealing No.
Name
Minnesota Unique No.
Minnesota Statutes,Chapter 1031 or W-series No.
161 e v (Leave blank If not known)
Township Name Township No. Range No. Section No. Fraction(sm.i Ig.) Date Sealed c Date Well or Boring Constructed
u u u
. ..� , 6. —
�i� r K Cl Ic1 t
NTerical-,Streerf Address or Fire Number and City of Well or Boring Location
(:() kn ) Ca("N-3
1 k UL �, � ✓ Depth Before Sealing /X 1--( ft. Original Depth / ?
L! ft.
�
Show exact location of well or boring Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL
in section grid with"X". location, showing property [Single Aquifer ❑Multiaquifer
lines,roads,and buildings.
N 0`(j h k‘ WELL/BORING Measured 0 Estimated
I I ‘,��` �'� '7 Water Supply Well 0 Monit.Well
❑ nv.Bore Hole Cl Other JO Lf ft. below ❑above land surface
wT `, 1 , 'E \ I CASING TYPES)
I 1 - 1 I
--4-1---t---1 1—T oc r`' Steel El Plastic ❑Tile ❑ A'Other 7 13 c7i�
I 1 I I smile bJ,_,00 -,,t. A✓ CASING
I Diameter Depth Set in oversize hole? Annualar space initially grouted?
S 4 ! l Yes o ❑YesNo [Unknown
f mne in.from `� ,to t ft. ❑ 0
PROPERTY OWNERS NAME in.from to ft. ❑ Yes ❑No 0 Yes 0 No ❑ Unknown
+< . 4 `-S k . c- -„6r�n
Property own # it
s mailing address if different than well location address Indicated above. in.from to ft. ❑Yes ❑No ❑ Yes ❑No 0 Unknown
5 SCREEN/OPEN HOLE
Screen from to ft. Open Hole from to ft.
OBSTRUCTION/DEBRIS/FILL
WELL OWNERS NAME 4 Obstruction ❑ Debris ❑ Fill ❑ No Obstruction
—c-9 w1/44._ jr),Well owners mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill / l ,1)i I/`,.P h . . 'i 1 ,LAn p
1 ,
Obstruction/Debris/Fill removed? EcYes ❑ No
PUMP
Type S ,-. L. IA-, . , < . 1, II C
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed CINot Present 0 Other
FORMATION
If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
N - _ - �No Annular Space Exits
❑ Annular space grouted with tremie pipe
❑ Casing Perforation/Removal
in.from to ft. 0 Perforated Cl Removed
in.from to ft. 0 Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) 11 p
Grouting Material p ti t k, . I(from (J to /F 4 ft. yards 7 bags
from to ft. yards bags
from to ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS
IU C'w 1,.,r o, k v,CI L1 I r (,,/41, (1
Other unsealed well or boring on property? F Yes ❑ No
Lk 1
f\J ` , E 4 t c LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is
\\ tt true to the best off�my knowledge.
Contractor Business Name License or Ft
eegistration No.
L/,1,..
„...0,4„.1......._ —
Authorized Represenfatfi a Sgn'atfire "Date
h -1( ' h •• --\- , 17
LOCAL COPY
H 1 0 2 8 6 7 Name of Person Sealing Well or Boring
HE-01434-02 10/95R
STATE OF MINNESOTA - MINNESOTA UNIQUE WELL NO.
DEP8RT!ENT OF HEALTH 127317
WATER WELL RECORD for Water Sample
1. LOCATION OF WELL, Minnesota Statutes 156A.01-.08
CountyDeme Fraction Section Number Twnship Number Range Number 3. PROPERTY OWNER'S NAME
t
1111101101. illtint n in 23
f/Distance and Direction from Road Intersections or Street Address and City of Well Location-
Show exact location of well in section grid with "X." Sketch map of well location. 4. WELL DEPTH (completed Date of Completion
, N 1 24 ft. 3
I 1 1 1 5 10 Cable tool 40 Reverse 70 Driven 100 Dug
W — E
p 20 Hollow rod 50 Air 80 Bored 110
-t- -' -�- `- }mt.
Tina ITEM _kta uun 71/Rotary 60 Jetted 9OPwer Auger
I
UUU 77 t�3 ����d///
) ' 6. USE
Rim
s
IFaLED 1Domeatic 4OPublic Supply 71_1lndustry
1--------1 male 20 Irrigation 50 Air Conditioning RO Commercial
2. FORMATION LOG COLOR HARDNESS OF FROM- TO
FORMATION 30 Test Well 60
7. CASING I HEIGHT: Above/Below
DIAM.
Threaded130 1 Welded 03 Surface ft.
*wit Sod 10 200 4 Black - 2atm, Galy. 0
--41141W
in. to ft. depth Weight sak.2 200 200
in. to ft. depth
io. to - ft. depth Drive Shoe? Yee JE No_
78. SCREEN Or open hole
Make ! from ft. to ft.
Type f ...'._. i✓' Dia. '
Slot/Gauze Length
FITTINGS:
Set between rat ft. and in ft.
ft. and Et.
ft. and ft.
9. STATIC WATER LEVEL
Allffft. below ['above Dnte Measured
land surface
10. PUMPING LEVEL (below land surface)WO n'
ft. after 4 hrs. pumping g.p.m.
_. ft. after bra. pumping g.p.m•
E V}I _ _ _, U. WELL HEAD COMPLETION
. ` s •" WIPStleee adapter 20Basement offset 3❑At least 12" above
grade
�/�/� 12. Well grouted?
CT - 4 f Eites Oso Cu. Yds.
`���vVV 1❑Neat cement 2❑Bentonite /102211010440411931—3 f'
Depth: from ft. to ft.
1TY OF O I from ft. to ft.
13. Nearest source of possible contamination SOU
feet direction type
Well disinfected upon completion? Yes ill No 0
14. PUMP
Date installed
_ El Not installed
Manufacturer's Name
Model Number HP volts
_. Length of drop pipe 12$ ft. capacityg.p.m.
Material of drop piper 12
_____ --_. — Type: 1XSubmersible 30 L.S. Turbine 50 Reciprocating
20 Jet 40 Centrifugal 60
16. WATER WELL CONTRACTOR'S CERTIFICATION
This well vas drilled under my jurisdiction and this report is true to
_ —- the best of a5'knowledge and belief.
Use a second cheat, if needed. *,y 1.004. 1111
15. REMARKS,ELEVATION, SOURCE OF DATA, etc. Licensee Business Nane ?? .4LL�e'rcnse No.
Address # li . '��3:ffia
Signe `if'/—e..)� 'e to-; - Date 1$4411. .
r� Authorized Representative
— ter►
LOCAL COPY Name of Driller 7/74 30M